A couple of years ago I had the pleasure of chairing the Nurse in Washington Internship Program (NIWI) for the Nursing Organizations Alliance (NOA). Nurses from all over the country attended, to increase their political savvy, and to discuss healthcare policy with their elected officials. While there, I experienced one of those flashes of insight (also known as “aha” moments) in which I realized that I had gained most of what I needed to know about advocating for patients in my work as a hospital nurse leader. I found myself reminiscing about an early lesson learned when a physician colleague and I could not come to an agreement. He hadn’t concurred with the nursing house supervisor, either, which was why the issue had escalated to me, the hospital chief nurse executive. I had explained to him that every bed in our sole community hospital was full, and that a dozen patients were now lying on gurneys in the emergency department hallway waiting for beds, with more patients flowing into the standing-room-only waiting area. Of the several patients he was attending, two had been assessed by the nursing staff as ready for discharge tonight, rather than the next morning. He refused to write discharge orders, even though he agreed they were stable enough to go home.

Mystified, I asked him to help me understand his rationale, especially since he had just made a speech at our capital budget meeting about how doctors are the major advocates for patients. “I am my patient’s advocate,” he replied, “That’s why I’m holding onto those beds in case any of my other patients needs to be admitted before tomorrow morning.”

That’s when I realized that we were poles apart in our definition of advocacy, at least on this night. I was advocating for the entire patient population, through distribution of scarce resources based on most need. He was advocating for his own patients, even if they did not have a need for the resources he was attempting to hoard.

This was the first time I realized that advocacy has various meanings to different people and even to the same people at different times. To many people advocacy appears to primarily refer to attempts to influence public policy or resource allocation through the political process. To others it’s about gaining rights for certain groups. In some countries, such as Scotland and India, advocate is a synonym for professional lawyer. In the following collection of articles, the word is a synonym for professional nurse.The authors featured in this issue share their ideas about the responsibility and privilege nurses have to advocate for our patients, as specific persons and as populations, and for our profession as a whole.Each addresses advocacy from a different point of view, but all offer thoughtful and broad discussions of what we can, and must, do as advocates who will work to improve healthcare across the continuum, for everyone.

Louise Selanders and Patrick Crane begin this topic with the most famous historical nursing leader. In “The Voice of Florence Nightingale on Advocacy,” they state that while Nightingale did not directly use the word advocacy as a nursing responsibility, her actions and her writing were consistently about advocating for change. The woman who is credited with establishing nursing as a profession, rather than a domestic service, advocated for individuals, specific groups, and society as a whole. She was aware of the need to overcome gender bias through increasing opportunities for women. She insisted on equity of care regardless of religion or faith, and was a crusader for basic human rights. Selanders and Crane remind us that her techniques became the basis for modern nursing leadership theories, and that it is clear Florence Nightingale knew the importance of both leadership and advocacy.

Nightingale has been followed by generations of nurses who have identified the needs of patients and taken action to get these needs met. Mary Maryland and Rose Gonzalez offer examples of how this mission continues today in their article, “Patient Advocacy in the Community and Legislative Arenas.” They point out that because nurses are trusted by patients and the public as a whole, we can influence care in our own communities, our states, and our nation by taking part in the legislative process. We are reminded that we have important information to share with our governmental representatives and policy makers about the effects of their choices and legislation on individuals and groups. The authors educate readers on how the lawmaking process works along with ways for nurses to get involved. Their specific examples of advocacy for individual patients and community programs are especially helpful for nurses who are working to improve healthcare locally.

In her article, “Role of Professional Organizations in Advocating for the Nursing Profession,” Jennifer Matthews reviews the characteristics of a profession and the history of professional nursing organizations, primarily in the United States. She details how societal changes, historical events, and the emergence of specialization have given rise to multiple nursing membership groups, while the American Nurses Association (ANA) and ICN have remained the only full service (representing all nurses, regardless of specialty) organizations. Her cogent message to the profession as a whole is that there is greater strength in numbers, and that the nursing profession will have stronger advocacy outcomes if we unite by joining these organizations to advocate for all nurses.

Karen Tomajan gives explicit ideas on how nurses in varied roles can support the profession and all of their nursing colleagues. In “Advocating for Nurses and Nursing” she talks about how, regardless of employment setting, we can consciously and conscientiously work together to build support for changing what needs to be changed for our patients and for ourselves. From point of care practitioners who must know how to get the voice of the front line heard by decision makers; to nursing managers and administrators who must advocate for healthy work environments; to nursing educators who have an important role in forming nurses’ professional identity, nurses must be prepared as advocates. Tomajan’s practical advice includes the development of specific scripts that can inform others about what it is that nurses do for our patients and organizations.

David Benton, CEO of the International Council of Nurses (ICN), shares stories about nurses of five developing countries who are working to improve quality care, either individually or collectively through their professional organizations. In his article, “Advocating Globally To Shape Policy and Strengthen Nursing’s Influence,” he explains a project conceived by a nurse to combat dengue fever in El Salvador as well as a nursing led project to provide testing for HIV and AIDS in remote areas of Papua New Guinea. He expresses his admiration for the nursing organization in Iran which has produced an ethical code of conduct for nurses and the movement to improve the quality of nursing education and professional standards in Rwanda. His depiction of the way nurses are pursuing a partnership with the government in Paraguay to meet the nation’s healthcare needs exemplifies the reality that advocating for the nursing profession is also advocating for patients. Benton’s underlying theme is that nurses throughout the world are leading their countries to better health. Acknowledging the need for even more nursing leadership, he reminds us that ICN sponsors three programs to build it: the Leadership in Negotiation Program, the Global Leadership Institute, and Leadership for Change.

In an economically challenged environment, all nations are looking for ways to transform healthcare by increasing value, (described as quality combined with efficiency) in our care delivery systems. As nurses we know how every one of our roles adds value to our patients, our communities, our countries, and our world.These five articles remind us that it is through advocacy that we can be sure others know this as well. The journal editors invite you to share your response to this OJIN topic addressing Nurse Advocates either by writing a Letter to the Editor or by submitting a manuscript which will further the discussion of this topic which has been initiated by these introductory articles.

Author

Dr. Kathleen Sanford is the system senior vice president and chief nursing officer for Catholic Health Initiatives. She currently serves as principle investigator for research on the use of virtual technology and nurse coaching. A retired Army nurse corps officer, she has held nursing positions in direct patient care and administration. She has also been associate faculty for a number of colleges of nursing.

Dr. Sanford is past president of the American Organization of Nurse Executives, and past president of the Northwest Organization of Nurse Executives. She has served on the nursing TriCouncil, the coordinating team of the Nursing Organizations Alliance, the boards of the American Hospital Association, the American Business Women’s Association, numerous college nursing advisory boards and various editorial boards. Previously, she was a member of Congressman Rick White’s (WA) advisory committee on Veteran’s Affairs.